Undertreatment of Women Linked to More Heart Attack Deaths

< Dec. 10, 2008 > -- Recent studies show an increase in deaths and a difference in the medical treatment given to women compared to men when suffering a severe heart attack.

More than 78,000 people treated for heart attacks at 420 US hospitals between 2001 and 2006 found the same overall in-hospital death rate for men and women. However, a study reveals 10.2 percent of women with a severe form of heart attack called ST-elevation myocardial infarction, or STEMI, died, compared to 5.5 percent of men with the same diagnosis, according to an article in the medical journal Circulation.

The study found there was clearly a difference in the treatment given to men and women. For example, women were 14 percent less likely to receive early aspirin, 10 percent less likely to be given beta blocker medications, 25 percent less likely to receive reperfusion therapy to restore blood flow, and 13 percent less likely to have artery-opening angioplasty within 90 minutes of arrival at the hospital.

Results Validate a Disparity

Dr. Hani Jneid, an assistant professor of cardiovascular medicine at Baylor College of Medicine in Houston, says, "We believe that a part of it may be related to the fact that women are undertreated." Dr. Jneid states, "There is evidence across the board of undertreatment."

"We obviously could not assess the appropriateness of the treatments," Dr. Jneid adds. "But the results point to the fact that there might be some sex-related disparity in treatment that needs to be addressed by physicians."

Possible Reasons for Survival Rate Differences

According to Dr. Gregg C. Fonarow, a professor of cardiovascular medicine at the University of California, Los Angeles, while in theory "there is no intrinsic reason why there should be a difference" in survival rates between the sexes, there are several possible explanations.

Those explanations may start with the symptoms reported by people having heart attacks and then go on to the treatment they receive, he says. "Women when presenting with a heart attack tend to be older and have other comorbid conditions [health problems]," Dr. Fonarow says, "But even when we adjusted for that, we found a 12 percent difference."

Also, "women present more atypically," he says. "They are less likely to have sternal chest pain or pressure, just general symptoms like shortness of breath or other symptoms that are non-specific."

A Focus on Coronary Disease in Women

Coronary artery disease, or CAD, is a leading cause of death in the US among women. It effects one in 10 over the age of 18 according to the National Institutes of Health (NIH).

Dr. Laura Wexler, senior associate dean at the University of Cincinnati College of Medicine says some basic biological differences between the sexes might be partially responsible for the discrepancy in survival.

"For women ages 50 to 60, I wonder whether the biology of a heart attack may be different," she says. "The question is whether menopause enhances the severity of heart attacks." The incidence of heart attack in such perimenopausal women is lower, Dr. Wexler says, "but when they do get it, the mortality rate is higher."

Still, Dr. Wexler adds, "I think there are impediments to the diagnosis of coronary disease in women, including, but not exclusively, some lack of appreciation in some sectors of the importance of coronary disease in women."

An Opportunity to Improve Care

The American Heart Association has started a program called "Mission: Lifeline" that is designed to educate people about the symptoms of a heart attack so they can seek treatment quickly and also "enable hospitals to make quicker diagnoses," Dr. Fonarow says. "These kinds of quality-improvement programs can lead physicians, emergency room attendants and paramedics to close the gap and eventually eliminate sex-related differences."

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Coronary Heart Disease and Risk Factors

Coronary heart disease, or coronary artery disease (CAD), is characterized by the accumulation of fatty deposits along the innermost layer of the coronary arteries. The fatty deposits may develop in childhood and continue to thicken and enlarge. This thickening, called atherosclerosis, narrows the arteries and can decrease or block the flow of blood to the heart.

Controlling risk factors is the key to preventing illness and death from CAD. Risk factors for CAD often include high LDL cholesterol, high triglyceride levels, and reduced HDL cholesterol. High blood pressure, physical inactivity, smoking, and diabetes are also significant risk factors. Consuming a high saturated fat diet and obesity can also be contributors.

The symptoms of CAD will depend on the severity of the disease. Some people with CAD have no symptoms, some have episodes of mild chest pain, and some have more severe chest pain.

If too little oxygenated blood reaches the heart, a person will experience chest pain called angina. When the blood supply is completely cut off, the result is a heart attack, and the heart muscle begins to die. Some persons may have a heart attack and never recognize symptoms. This is called a "silent" heart attack.

When symptoms are present, each person may experience them differently. Symptoms of CAD may include:

CAD is diagnosed by your physician. You will most likely have a physical examination that includes a thorough medical history. Additional diagnostic procedures such as EKG, stress test, cardiac catheterization, or nuclear scanning may be performed.